K, I have a lot of experience with pulse lavage in deep full thickness wounds (mostly in the early 2000s). I believe that pulse lavage has lost favor related to the high risk for spreading microorganisms via water droplets that inevitably spray back out of the wound. Two other developments have lead to the reduction in pulse lavage use including VAC instill (NPWT) and Celleration Mist therapies.  That being said pulse lavage does have a place in the care of patient’s if the wound is grossly contaminated (say status post traumatic injury to flush debris).

I would review the goals that you expect to achieve when treating the patient with pulse lavage. Typically, pulse lavage helps to reduce slough and clean a contaminated wound bed.  Depending on your goals I think there are better solutions. To reduce or loosen slough in high draining wounds I recommend DrawTex (SteadMed). If you fear contamination (and in a hospital setting) I would recommend VAC instill with Microcyn as the irrigant. If the patient is at an ECF, Home Care, or being seen at a wound clinic I would consider going with our classic antimicrobial silver (We use a ton of Silvadene) , but opt for an silver alginate if the patient can’t get the dressing changed daily.

Thanks again for the question,

Matthew

• necrotic tissue with eschar present
• untreated osteomyelitis
• non-enteric and unexplored fistulas
• malignancy in the wound
• exposed vasculature
• exposed nerves
• exposed anastomotic site
• exposed organs

FDA Safety Communication: UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems

Date Issued: February 24, 2011

Retrieved: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm

Week 1 Pressure Ulcer Evidence Based Treatment Pathway

1. Relieve Pressure                              Support Surfaces / Other Offloading Devices
2. Manage Infection                            Culture / Antimicrobials
3. Remove Avascular tissue              Debride (Leave heel wounds intact unless infected)
4. Optimize Nutrition                          Pre-albumen / Dietary consultation
5. Control Moisture                             Absorbent dressing
6. Reduce Healing Delays                  Treat Co-morbid Conditions
7. Fill Dead Space                                  Fill to volume of wound (Don’t over pack)
8. Resolve aggravating conditions  Treat friction, shear, moisture, and incontinence
9. Sponsor Granulation                      Consider NPWT

Week 4 Pressure Ulcer Evidence Based Treatment Pathway – If the pressure ulcer heals less than 75% over the first 4 weeks* then consider the following adjunctive therapies or treatments:

1. Sponsor Granulation                      NPWT (Revisit use if not previously ordered)
2. Fill volume                                          Apply Dermal substitutes
3. Revise tissue                                      Surgical Intervention
4. Treat Chronic Conditions              Debride and Treat with Collagen

10 Week Benchmark: The median days to healing is 73 days for large (>4cm2) ulcers¹.

* Note: Wounds that did not decrease in area by 77% after 4 weeks were significantly less likely to  heal² (a 75% closure rate at 4 weeks was selected due to wound measurement conventions)

Sources

1. Bergstrom et al., 2008.  NPUAP & EPUAP. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Pg 54.
2. Van Rijswijk L. Full-thickness pressure ulcers: patient and wound healing characteristics. Decubitus. 1993;6:16–2

Week 1: Venous Wound Evidence Based Treatment Pathway

1. Confirm Venous Etiology              Venous Duplex Ultrasound
2. Rule Out Arterial Etiology             ABI
3. Apply Compression                         Multilayer compression
4. Remove avascular tissue                Debride Non-Viable Tissue
5. Optimize Nutrition                          Dietary Consultation
6. Protect Surrounding Tissue           Barrier Paste
7. Control Moisture                             Absorbent Dressing

Week 4 Venous Wound Evidence Based Treatment Pathway: If the venous leg ulcer heals less than 30% over the first 4 weeks* then consider the following adjunctive therapies or treatments:

1. Sponsor Granulation                       NPWT
2. Introduce  Growth Factors            Skin Substitute
3. Revisit diagnosis                              Rule Out Associated Etiologies

24 Week Benchmark:  A benchmark 49% of the venous ulcers treated with compression therapy alone in the control arm of a randomized clinical trial healed at 24 weeks¹.

*Note: “Data suggests that a venous leg ulcer that fails to decrease in size by 30% (percentage area reduction) of its initial size over the first 4 weeks of treatment has a 68% probability of failing to heal within 24 weeks”².

1. Falanga V, Margolis D, Alvarez O, et al. Rapid healing of venous ulcers and lack of clinical rejection with allogeneic cultured human skin equivalent. Arcj Dermatol 1998;134:293-300.

2. Kanter J, Margolis D, A multicenterstudy of percentage change in venous leg ulcer area as a prognostic index of healing at 24 weeks. Br. J Dermatol. 2000;142(5):960-964.)

Week 1 of Diabetic Wound Evidence Based Treatment

1. Relieve Pressure                              Offloading Devices
2. Manage Infection                            Antimicrobials
3. Remove Callus                                  Debride Callus
4. Remove Avascular Tissue             Debride Non-Viable Tissue
5. Optimize Nutrition                          Glucose Control
6. Protect Surrounding Tissue         Barrier Paste
7. Control Moisture                             Absorbent dressing

Week 4 of Diabetic Wound Evidence Based Treatment: If the diabetic foot ulcer heals less than 50% over the first 4 weeks* then consider the following adjunctive therapies or treatments:

1. Assess Circulation                            T-com study
2. Sponsor Granulation                      NPWT
3. Introduce  Growth Factors           Skin Substitute / Regranex
4. Improve Microcirculation             Hyperbaric Oxygen Therapy (Wagner 3 or Greater Diabetic Wounds)

20 Week Diabetic Wound Benchmark: 67% of diabetic foot ulcers remain unhealed after 20 weeks of care¹.

*Note: “50% percentage area reduction at four weeks was significantly associated with healing at 12 weeks”².

1. Kantor J, Margolis DJ. Expected healing rates for chronic wounds. WOUNDS. 2000;12(6):155-158.

2. Snyder R, Kirsner R, Warriner R, Lavery L, Hanft J, & Sheehan P, 2010. Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes. Ostomy Wound Management. 2010;56 (suppl 4):S1-S24.

Best Wishes, Matthew Livingston RN

Medical Device Firm looking for a WOCN to join their growing team as a Clinical Consultant.  My client is a well-established medical device company with an innovative approach to treating incontinence.  This Clinical Consulting role will include prospective and retrospective surveillance of incontinence in hospitals across the Western region of the country.  Ideal candidates would live in Denver or Phoenix.

This is a great opportunity that would offer autonomy, a great compensation package and the ability to pass along your knowledge to improve patient care.

If anyone is interested in learning more, please contact Nancy Di Vito directly at ndivito@worldbridgepartners.com or 847-559-7000.

A

Dear A, Great Question.  The first decision I make when choosing negative pressure (VAC) for venous etiology wounds is which types of venous wounds I would exclude. Limiting conditions or symptoms include:

1. Infection, or an inflammatory reaction along the periwound or the extremity itself.

Note: while infection of venous wounds does occur it is often mistaken as the lone cause of redness along the extremity or peri-area of the wound. More commonly, this redness (erythemia) is related to an inflammatory process common with venous wounds (see a great explanation below*). If this problem is preventing the application of Wound Vac therapy then I recommend a Medrol dose pack which typically does this trick in reducing the inflammatory process.

2. Fragile or weeping skin tissue proceeding from the borders of the wound out to the greater part of the lower extremity (disallowing adhesion of wound vac drape or duoderm thin without the further opening of wounds along the extremity).

This being said, you can treat fragile or weeping skin just a few inches away from the wound with a few simple tricks.

First, on outright weeping skin a recommend a layering process that starts with the application of Non-sting skin prep followed by anti-fungal powder.  Alternatively repeating (at least 10 repeated applications) the application of these two products achieves two goals as the weeping areas are covered in a way that limits their drainage and the skin prep provides a great tacky surface for which the wound drape to adhere.

Second, along the edges beyond the weeping or fragile skin tissue place a Duoderm thin (ConvaTec). I have found that Duoderm Thin is about the only dressing that prevents the fluid from working its way under it a high draining wound with or without NPWT.  I also recommend placing stoma paste (ConvaTec) in the trenches of skin that the Duoderm Thin can’t secure to (See the following image). Once hardened place the Duoderm Thin over the Stoma Paste.

Finally, at this point place the VAC Foam in the wound bed. I recommend the  the V.A.C.^® GranuFoam™ Bridge Dressing (See Picture Below). This dressing allows you to concisely weave the pre-sized bridge dressing through the multilayer compression dressing. When applying the wound drape place skin prep to skin (that is intact) and over the Duoderm Thin to provide a more wound drape dressing.

“Venous reflux (or valve failure) or other vein conditions can lead to increased pooling of blood, causing venous hypertension (increased pressures in the veins of the lower leg), which leads to the pooling of blood. These venous conditions may come from more superficial veins (like varicose veins), deeper veins (related to deep vein thrombosis or DVT) or from perforator veins, which connect the veins of the superficial and deep vein systems. When these high pressure conditions exist, fluid can leak out into the surrounding tissues, inflammation of the tissues occurs, and the normal transfer of nutrients and oxygen to the tissues is impaired. Over time, the diminished level of nutrients and oxygen and the inflammation created causes damage to the surrounding tissues, which can result in skin discoloration and tissue death” (retrieved from www.veintreatment.com).

Total Contact Casts are typically intended for diabetic planter ulcers.

Hold or don’t initiate a Total Contact Cast if:

1. Infection
2. Critical limb ischemia Tcom < 30mmHg
3. Major illness / Unstable patient
4. Frail / Bad hip or back
5. Non-compliance (overactive)

Quick Fixes for Total Contact Cast Complications:

1. Heavy Drainage – Biweekly changes
2. Toe Drainage – Open toe cast
3. Discomfort – Add padding
4. Chafed skin -  Add padding
5. Pre-ulcerated lesion on pressure point – offload pressure point
6. New ulcer – offload pressure point

Consider a DH Walker if you are unable to control for:     

1. Discomfort with extra padding
2. Chafed skin with extra padding
3. New ulcer formation continues regardless of offloading
4. Lower extremity joint problems

Note: DH Walkers are hard to ambulate in for patients with a weak gait. If this is the case consider a walker. If it is still difficult for the patient to ambulate consider a wedge shoe (Darco).

Note: Consider a Crow Boot for patients who have a rocker bottom (Charcot) foot deformity.

Diabetic Etiology 20 week of healing benchmark

Research indicates that 67% of diabetic foot ulcers remain unhealed after 20 weeks of care. (Note: Average healed at 20 weeks is 33%)

Kantor J, Margolis DJ. Expected healing rates for chronic wounds. WOUNDS. 2000;12(6):155-158

RESULTS—Wound area measurements at baseline and after 4 weeks were performed in 203 patients. The midpoint between the percentage area reduction from baseline at 4 weeks in patients healed versus those not healed at 12 weeks was found to be 53%. Subjects with a reduction in ulcer area greater than the 4-week median had a 12-week healing rate of 58%, whereas those with reduction in ulcer area less than the 4-week median had a healing rate of only 9% (P < 0.01). The absolute change in ulcer area at 4 weeks was significantly greater in healers versus nonhealers (1.5 vs. 0.8 cm2, P < 0.02). The percent change in wound area at 4 weeks in those who healed was 82% (95% CI 70–94), whereas in those who failed to heal, the percent change in wound area was 25% (15–35; P < 0.001).

Percent Change in Wound Area of Diabetic Foot Ulcers Over a 4-Week Period Is a Robust Predictor of Complete Healing in a 12-Week Prospective Trial Peter Sheehan, MD1,Peter Jones, MSC2,Antonella Caselli, MD3 John M. Giurini, DPM3 and Aristidis Veves, MD3

10.2337/diacare.26.6.1879 Diabetes Care June 2003 vol. 26 no. 6 1879-1882

Nutrition

“Basic principles of nutritional management of a patient with diabetes mellitus to control glucose, hyperlipidemia, and hypertension should be applied to the patient who has developed neuropathic foot ulcers.”

Level of Evidence=C

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 24

Offloading

“Ensure adequate offloading of pressure through wound closure. Utilize assistive devices to provide support, balance, and offloading of the affected site.”

Recommendation

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 17

TCOM

A transcutaneous oxygen monitor study “is indicated to assess tissue perfusion when the lower extremity wound is not healing or an ABI or toe pressures can not be done due to incompressible arteries” (Grolman et.al. 2001: Hopf et al., 2006: Stalc & Poderos, 2002).

Level of Evidence = A

WOCNS, 2008. Guideline for Management of Wounds in Patients with Lower-Extremity Arterial Disease. Pg. 14

Negative Pressure Wound Therapy

Negative Pressure Wound Therapy  “has been demonstrated to be effective for the treatment of neuropathic/diabetic ulcers and skin graft and donor sites.”

Level of Evidence = B

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 27

Skin Substitutes

Skin Substitutes have the potential to stimulate, through topical activation the normal or enhanced activity of mechanisms involved in tissue repair.

(Gentzkow, Iwasaki, Hershon, Mengel, Prendergast, Ricotta et al., 1996; Gentzkow, Jensen, Pollak, Kroeker, Lerner, Lerner et al., 1999; Marston, Hanft, Norwood & Pollak, 2003)

Level of Evidence = 1b

Hyperbaric

“Hyperbaric oxygen therapy may be clinically effective in treating patients with limb-threatening diabetic wounds of the lower extremity (Wagner grades III and IV)

Level of Evidence = A

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 27